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  • Fresno Site 2022 – 2023 Enrollment Application

    (for adult students 18 and older)
  • Dear Prospective Student,

    Thank you for your interest in YouthBuild Charter School of California (YCSC). To consider your application, all of the following documents are required. Please return this checklist with your application and all documents for consideration. Incomplete applications will not be accepted.

    • Signed Letter / Proof of Acceptance to local YouthBuild program
    • Confirm student is NOT enrolled in two schools at the same time. PAR and/or Withdraw Slip from previous school with an exit date will be acceptable
    • Completed Enrollment Application:
      • YCSC Enrollment Application
      • Student Agreement
      • Student Release Form
      • YouthBuild Emergency Card
    • Household Income Data Collection Form
    • Birth Certificate – COPY
    • Identification card reflecting current address: Driver License or CA ID - COPY
    • Utility Bill – COPY
    • Proof of Household Income (e.g. Check stub, MediCal Lifeline or Public Benefit Award Letter, Tax Return or No Income Certification) - COPY
    • Special Education Documents (IEP) and 504 Plan or Opt Out Letter – COPY
    • Immunization Records - TDAP IS A REQUIREMENT (Minors Only)
    • Official School Transcripts
  • Once you have completed this online application you must submit the above documents to your counselor in order to complete your enrollment.

    If you are currently homeless, you may be exempt from having to submit all of the above documents prior to enrollment. Please talk to your counselor if you are having trouble obtaining the above documents.
  • Student Information:

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  • Race/Ethnicity Surveys

    New federal race and ethnicity data collection/reporting requirements beginning in 2009-2010 require all students to identify ethnicity from the two choices below.
  • No matter what ethnicity is selected above, at least one race must also be selected below.

  • PREVIOUS SCHOOLING INFORMATION

  • List all previous high schools you attended (most recent first). If you have not attended high school previously, please write N/A in the box for High School #1.

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  • Parent/Guardian Education Level Survey

    The California Education Code requires all schools collect the below information about students and submit this information to the State. If you do not know the education level of one of your parent/guardians, you may select "declined to state."
  • HOME LANGUAGE SURVEY

    The California Education Code requires all schools collect the below information about students and submit this information to the State.
  • Dashboard Alternative School Status (DASS)

    If you are unsure which, if any, options to check below, we recommend you consult with your school counselor.
  • APLUS+ Schools Home Survey

  • Household Income Data Collection

    Please fill out the survey below. If you are unsure of what to put for household size or income, please see the instructions at the bottom of this page.
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  • Who should I include in “Household Size”?

    You must include yourself and all people living in your household, related or not (for example, children, grandparents, other relatives, or friends) who share income and expenses. If you live with other people who are economically independent (for example, who do not share income with your children, and who pay a pro-rated share of expenses), do not include them.

    • What is included in “Total Household Income”? Total Household Income includes all of the following:
    • Gross earnings from work: Use your gross income, not your take-home pay. Gross income is the amount earned before taxes and other deductions. This information can be found on your pay stub or if you are unsure, your supervisor can provide this information. Net income should only be reported for self-owned business, farm, or rental income.
    • Welfare, Child Support, Alimony: Include the amount each person living in your household receives from these sources, including any amount received from CalWORKs.
    • Pensions, Retirement, Social Security, Supplemental Security Income (SSI), Veteran’s benefits (VA benefits), and disability benefits: Include the amount each person living in your household receives from these sources.
    • All Other Income: Include worker’s compensation, unemployment or strike benefits, regular contributions from people who do not live in your household, and any other income received. Do not include income from CalFresh, WIC, federal education benefits and foster payments received by your household.
    • Military Housing Allowances and Combat Pay: Include off-base housing allowances. Do not include Military Privatized Housing Initiative or combat pay.
    • Overtime Pay: Include overtime pay ONLY if you receive it on a regular basis.

    How do I report household income for pay received on a monthly, twice per month, b-weekly, and weekly basis?

    • Determine each source of household income based on above definitions. Households that receive income at different time intervals must annualize their income as follows: o If paid monthly, multiply total pay by 12 o If paid twice per month, multiply total pay by 24 o If paid bi -weekly (every two weeks), multiply total pay by 26 o If paid weekly, multiply total pay by 52
    • Add all annualized pay togeth er to determine the total annual household income entered in Part II, 2. If your income changes, include the wages/salary that you regularly receive. For example, if you normally make $1,000 each mo nth, but you missed some work last month and made $900, put down that you made $1,000 per month. Only include overtime pay if you receive it on a regular basis. If you have lost your job or had your hours or wages reduced, enter zero or your current reduced income.

    For additional information on Household Size and Gross Household Income, please see the Eligibility Manual for School Meals on the U.S. Department of Agriculture Guidance and Resource Web page at http://www.fns.usda.gov/cnd/guidance/default.htm.

     

  • The information submitted on this form is a confidential educational record and is therefore protected by all relevant federal and state privacy laws that pertain to educational records including, without limitation, the Family Educational Rights and Privacy Act of 1974 (FERPA), as amended (20 U.S.C. § 1232g; 34 CFR Part 99); Title 2, Division 4, Part 27, Chapter 6.5 of the California Education Code, beginning at Section 49060 et seq.; the California Information Practices Act (California Civil Code Section 1798 et seq.) and Article 1, Section 1 of the California Constitution.

  • Release Survey

  • Special Education Services/ 504 Plan

    Questions 1-4 are for students up to age 22. Question 5 is for students 22 and older.
  • If you selected NO for all of the questions above, please sign below and proceed to the next page of the application. If you selected YES on any of the questions above, please do not sign below and instead review and sign in the next section.

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  • If you selected YES on any of the questions in the Special Education Survey above, please sign below and provide the counselor a copy of the IEP, including an exit IEP.

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  • Agriculture and Gifted/Talented Survey

  • I certify that all of the statements and information given above and in the previous two sections are true and correct to the best of my knowledge:

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  • Master Agreement

  • YouthBuild Charter School of California is a school of CHOICE. When you sign this agreement, you are agreeing that you choose this school over all others you are entitled to attend or have your child attend. YouthBuild Charter School of California is WASC accredited.

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  • Student Release Form

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  • As an adult student (18 and over) you may give permission to YouthBuild Charter School to release your student information to the certain individuals at your discretion (your parents/guardians, spouse, etc.) Student records may include attendance records, grade reports, discipline reports and any other information that pertains to my progress. If you would like to give your permission for any individuals to access your student records, please list their names below. Otherwise, you can leave the sections below blank.

     

    I give permission to YouthBuild Charter to release my student information to the individuals listed below:

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  • Emergency Information 2022-23

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  • IN CASE OF EMERGENCY, PLEASE CONTACT:

  • Health Information

  • In case of accident or other emergency, I hereby authorize a representative of the school to make arrangements considered necessary for me to receive medical or hospital care, including necessary transportation. Under such circumstances, I further authorize the physician named below to undertake such acts and treatment as he/she considers necessary. In the event said doctor is not available, I authorize care and treatment to be performed by any licensed physician or surgeon.

  • The undersigned hereby agree to bear all costs incurred as a result of the forgoing. This authorization will remain in effect until revoked by the undersigned in writing.

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  • Local Educational Agency Name Housing Questionnaire

  • The information provided below will help the LEA determine what services you and/or your child may be eligible to receive. This could include additional educational services through Title I, Part A and/or the federal McKinney-Vento Assistance Act. The information provided on this form will be kept confidential and only shared with appropriate school district and site staff.

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  • Your child or children may have the right to:

    • Immediate enrollment in the school they last attended (school of origin) or the local school where you are currently staying, even if you do not have all documents normally required at the time of enrollment.
    • Continue to attend their school of origin, if requested by you and it is in the best interest of the student.
    • Receive transportation to and from their school of origin, the same special programs and services, if needed, as provided to all other children, including free meals and Title I.
    • Receive the full protections and services provided under all federal and state laws, as it relates to homeless children, youth, and their families.
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  • If you have any questions about these rights, please contact the local homeless liaison, Tizoc Brenes, by phone at 213-741-2600 or by email at tbrenes@youthbuildcharter.org.

  • Informed Consent and Limits of Confidentiality

  • This letter is intended to inform and request your consent for yourself or your son/daughter to receive counseling services at our school site. The MSW interns along with a licensed clinician will provide assistance through case management, one-on-one counseling, crisis intervention, behavioral counseling, group counseling, telehealth, and workshops. If a need for treatment beyond the scope of services provided on site arises, you will be contacted to consent for such services. The intent is to provide support for yourself and/or your son/daughter, the school, and your family. The intern will complete documentation including progress notes, psychosocial assessments, and goals and is kept in a HIPAA compliant electronic records system. The intern will only be working with the student until the end of the school year unless the student voluntarily discontinues the service. At the end of the intern’s internship the intern will end communication with clients in order to ensure confidentiality.

    The intern works on a team with school staff and will need to notify staff of the working relationship between the intern and student and the basic services offered to the student. No other specific information regarding sessions will be provided to the school unless verbal consent is given by the student to do so.

    Electronic communication is allowed between MSW interns and clients for appointment/attendance reminders and for counseling sessions. Clients may not engage in electronic communications with interns outside of regular school day or for any other therapeutic reason including crises.

    During the process of providing these services all information exchanged will be kept confidential. Protected health information will not be shared with anyone outside of the school unless you or your son/daughter and/or parent sign a consent authorizing release of information.

    The following are exceptions to this policy:

    • Anyone working with a minor is required by law to:
      • Report any reasonable suspicion of child, elder , or dependent abuse to the appropriate county agency.
      • Notify an appropriate person and/or agency if the student indicates intent to physically harm him/herself or someone else.

    If you have any questions or need further clarification please feel free to ask.

  • I, , hereby certify that I have read the above and understand that I may meet with an MSW for counseling services.

    I,   *, hereby certify that I understand the limitations of confidentiality and electronic communications.         

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  • NONDISCRIMINATION STATEMENT

  • YouthBuild Charter School of California (YCSC) is committed to providing a working and learning environment free from discrimination, harassment, intimidation, abusive conduct or bullying. YCSC prohibits discrimination, harassment, intimidation, abusive conduct or bullying based on actual or perceived race or ethnicity, gender/sex (including gender identity, gender expression, pregnancy, childbirth, breastfeeding/lactation status and related medical conditions), sexual orientation, religion, color, national origin (including language use restrictions and possession of a driver’s license issued under Vehicle Code), ancestry, immigration status, medical information, physical or mental disability (including clinical depression and bipolar disorder, HIV/AIDS, hepatitis, epilepsy, seizure disorder, diabetes, multiple sclerosis, and heart disease), medical condition (cancer related and genetic characteristics), military and veteran status, parenting status, marital status, registered domestic partner status, age (40 and above), genetic information, political belief or affiliation (unless union related), a person's association with a person or group with one or more of these actual or perceived characteristics, or any other basis protected by federal, state or local law, ordinance, or regulation in any program or activity it conducts or to which it provides significant assistance.

    Discrimination is different treatment on the basis of a protected characteristic in the context of an educational program, work or activity without a legitimate nondiscriminatory reason that interferes with or limits the individual’s ability to participate in or benefit from the services, activities, or privileges provided by YCSC or includes an adverse employment action.

    Hostile environment harassment occurs when a target is subjected to unwelcome conduct on the basis of a protected characteristic, which is both subjectively offensive to the target and would be offensive to a reasonable person of the protected characteristics under similar circumstances, and is sufficiently severe, persistent, or pervasive so as to interfere with or limit an individual’s ability to effectively work or to participate in or benefit from the services, activities or opportunities offered by YCSC. Harassment may take many forms, including but not limited to, verbal remarks and name calling, graphic and written statements, or any conduct that may be threatening or humiliating. Harassment based on any of the above-protected categories is a form of unlawful discrimination and will not be tolerated by YCSC and can result in disciplinary action against the offending student or employee.

    Upon witnessing an act of discrimination, harassment, intimidation, abusive conduct or bullying based on actual or perceived protected characteristics, school personnel are required to take immediate steps to intervene when it is safe to do so. Once a school/office has express notice or reason to know of such conduct, whether carried out by employees, students or third parties, it should take immediate and appropriate steps to investigate or otherwise determine what occurred and take prompt and effective steps reasonably calculated to end the conduct, eliminate a hostile environment, if one has been created and prevent the conduct from occurring again. These steps should be taken regardless of whether an individual makes a complaint or asks the school/office to take action. Complainants are protected from retaliation. YCSC prohibits retaliation against any person who files a complaint or an appeal, reports instances of noncompliance, discrimination, harassment, intimidation, abusive conduct or bullying, or who participates in the complaint-filing or investigation process. This nondiscrimination policy applies to all acts related to school activity or school attendance within any school/office under the jurisdiction of the Superintendent of YouthBuild Charter School of California.

    For inquiries or complaints related to discrimination, harassment, intimidation or bullying of students based on actual or perceived protected characteristics, contact the Title IX/Bullying Complaint Manager:

    Dr. Rudy Cuevas
    155 W. Washington Blvd., Suite 944
    Los Angeles, CA 90015
    213.741.2600. ext. 205
    RCuevas@youthbuildcharter.org

    For inquiries or complaints related to employee-to-employee, student-to-employee, or work/employment related discrimination, harassment, abusive conduct or intimidation, contact your Human Resources Department.

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